What is the treatment for a distal humerus fracture?

Treatment of Distal Humerus Fractures

For displaced distal humerus fractures, surgical treatment with open reduction and internal fixation (ORIF) is the preferred approach to restore anatomy and allow early mobilization, while non-displaced fractures can be effectively managed with conservative treatment including immobilization for 3-6 weeks. 1, 2

Classification and Initial Assessment

• Distal humerus fractures are classified based on fracture pattern:

  • Extra-articular (AO/OTA type A)
  • Partial articular (AO/OTA type B)
  • Complete articular (AO/OTA type C)

• Initial imaging should include:

  • True lateral radiographs to assess alignment 3
  • Consider CT scan for complex intra-articular fractures to improve diagnostic accuracy 3

Treatment Algorithm

Non-displaced Fractures (displacement <5mm)

• Conservative management with:
  • Rigid immobilization with a cast for 3-6 weeks 3
  • Short arm cast with wrist in neutral position 3
  • Active finger motion exercises immediately to prevent stiffness 3
  • Ice application for first 3-5 days for symptomatic relief 3

Displaced Fractures (displacement >5mm)

• Surgical management with ORIF is indicated for:
  • Displaced fractures (>5mm displacement in any plane) 4
  • Intra-articular displacement 3
  • Unstable fracture patterns 2

Surgical Principles for Optimal Fixation

1. Parallel plating technique in the sagittal plane provides superior biomechanical stability compared to perpendicular plating 5
2. Key technical objectives:
   • All screws in distal fragments should pass through a plate
   • Maximize number and length of screws in distal fragments
   • Create interdigitating screw fixation for a fixed-angle construct
   • Achieve compression at the supracondylar level for both columns 5

Special Considerations

• For elderly patients with complex comminuted fractures and poor bone quality:

  • Consider total elbow arthroplasty as an alternative to ORIF 2
  • This is particularly important in low-demand patients with severe osteoporosis

• For fractures with severe bone loss:

  • Reconstruction using fibular strut allograft or fresh frozen osteochondral allograft may be necessary 6
  • Multiple surgeries may be required to achieve union

Rehabilitation Protocol

• After surgical fixation:

  • Begin early range of motion exercises as soon as stable fixation allows
  • Progressive weight bearing as tolerated
  • Strengthening exercises once healing is confirmed 3

• After conservative treatment:

  • Progressive range of motion exercises after immobilization period
  • Directed home exercise program 3
  • Gradual return to activities

Potential Complications and Management

• Higher risk of union complications in:

  • High-energy injuries
  • Open fractures
  • "Low" transcondylar (type A2.3 and A3) and simple intercondylar (type C1.3) fracture patterns 4
  • Non-operative treatment of displaced fractures 4

• Infection and implant-related complications:

  • More common in type C fractures treated operatively 4
  • Consider multimodal and opioid-sparing pain management protocols 3

• Stiffness:

  • Can result from excessive immobilization
  • Emphasize early motion when fixation is stable 3

Follow-up

• Radiographic follow-up at 3 weeks and at cessation of immobilization 3
• Approximately 90% of fractures unite within 12 weeks 4
• Evaluate for osteoporosis risk in elderly patients 3

Pitfalls to Avoid

• Inadequate fixation of distal fragments leading to loss of reduction
• Excessive immobilization causing stiffness and reduced range of motion
• Insufficient attention to the ulnar nerve during surgical approaches
• Using low-intensity pulsed ultrasonography (LIPUS), which does not accelerate healing 3